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Fax completed prior authorization request form to 8552473677 (Integrated population) or 8552467736 (SMI Entitle population) or submit Electronic Prior Authorization through CoverMyMeds or Subscripts.
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Fill in your personal information such as name, date of birth, and contact details.
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Individuals who are seeking Sublocade treatment as a medication-assisted therapy for opioid use disorder may need the Sublocade Request Form accessible PDF. This form is typically required by healthcare providers, clinics, or treatment centers to gather necessary information and documentation to evaluate the patient's eligibility and need for Sublocade treatment.
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The sublocade-request-form-mcazrbha-41420 accessible pdf is a form used for requesting sublocade medication in an accessible PDF format.
Patients who are prescribed sublocade medication by their healthcare provider are required to fill out and submit the sublocade-request-form-mcazrbha-41420 accessible pdf.
To fill out the sublocade-request-form-mcazrbha-41420 accessible pdf, you need to input your personal information, medical history, and details about your prescription as required in the form.
The purpose of the sublocade-request-form-mcazrbha-41420 accessible pdf is to provide a convenient and accessible way for patients to request sublocade medication.
The sublocade-request-form-mcazrbha-41420 accessible pdf requires information such as patient's name, contact information, medical history, healthcare provider details, and prescription information to be reported.
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